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2. Note
   This form must be completed, signed and submitted before the permit becomes valid.
4. Permit Number
5. Date
   Date
7. Qualifier's Name
8. Email Address
10. Company Name
12. Address
14. City
15. State
16. Zip Code
18. Phone Number
19. Fax Number
21. State License Number
22. PCCLB Number
24. Agreement
    By signing this fax /email permit sign on, it is agreed that you are the qualified contractor for this job and are accepting all pertinent City Ordinances and Building Codes.
26. Qualifier's or Authorized Agent's eSignature
28. Please note
    Electrical inspections require 24 hour notice. Leave all information required on the inspection line or you may not risk getting an inspection: 727-369-5834. If you are not registered in the City, please fax a current copy of your state license and county construction licensing board license to 727-369-5839.
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30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

* indicates a required field